Clinical Claim Review Nurse - Fully Remote
Core
Review medical records and post-service claims, apply clinical criteria to support accurate claim determinations, and serve as a clinical resource for internal teams.
Role type
Clinical Claim Review Nurse
Builds
Accurate medical claim determinations and compliance with regulatory requirements
Domain
Health Insurance / Claims Processing
Deliverable
dashboards & analysis
Required skills
Clinical judgment, regulatory compliance, medical record interpretation, trend identification, stakeholder consultation
Preferred skills
None stated
Technologies
Microsoft Office 365, EHR portals, VPN
Responsibilities
Review and interpret clinical documentation from medical records; Apply clinical criteria to evaluate post-service claims; Coordinate clinical resolutions independently; Serve as a clinical resource to customer service and claims processing teams; Identify trends, discrepancies, or potential fraud concerns; Maintain current knowledge of applicable laws and regulations
Seniority
Mid-level, hands-on IC